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Abstrak :
ABSTRAK
Dokumentasi keperawatan merupakan bukti pencatatan dan pelaporan yang dimiliki perawat dalam melakukan catatan keperawatan yang berguna untuk kepentingan klien, perawat dan tim kesehatan dalam memberikan pelayanan kesehatan. Desain penelitian adalah survei analitik dengan pendekatan cross sectional. Sampel berjumlah 173 perawat dari 14 ruang rawat dan lembar observasi kelengkapan dokumentasi berjumlah 80 dokumen. Hasil penelitian menunjukkan bahwa pelaksanaan dokumentasi keperawatan dalam kriteria baik sebesar 47,4% dan perawat yang melengkapi dokumentasi keperawatan sebesar 57,2%. Sedangkan faktor yang paling berkontribusi secara bermakna dengan kelengkapan dokumentasi keperawatan adalah Ruang Dinas (p= 0,002; α= 0,05) setelah dikontrol oleh umur, jenis kelamin, tingkat pendidikan, dan tipe kelas ruangan. Diharapkan bidang perawatan dapat melengkapi dokumentasi keperawatan dengan format yang sama, memberi kesempatan perawat untuk melanjutkan kuliah dan mengikuti pelatihan askep serta bertukar informasi atau gagasan antar ruang rawat. ABSTRAK
Factors Related to the Documentation Completeness of Nursing. Nursing documentation is proof of recording and reporting is owned nurses in nursing notes were useful to the interests of clients, nurses and health team in providing health services. The study design was an analytical survey with cross sectional approach. Amount of 173 samples taken in a total nurse of 14 ward and 80 observation sheets about completeness of documentation in nursing process. The results showed that the implementation of nursing documentation in good criterion of 47,4% and nurses who complete the documentation of nursing at 57,2%. The factors most significantly associated with completeness of nursing documentation is the ward (p= 0,002; α= 0,05) after controlled by age, sex, educational level, and class room type. Advice can be given to the field of nursing in hospital to complete the documentation nursing with the same format, allowing nurses to pursue graduate studies and follow nursing process training and exchange information or ideas between the ward.

Abstrak :
A research had been performed in order to get general description of the service of an oral complementary drug in the nursing ward of IRNA B of Perjan RS Dr. Cipto Mangunkusumo and it evaluated the operation of the oral complementary drug service was and also found out the correlation of the orderly medication instruction writing of the oral complementary drug, the orderly operation of the process of th oral complementary drug procurement, drug preservation, drug preparation, the handover the oral complementary drug to a patient, and communication, information and education (CIE) in the nursing ward of IRNA B relation to the orderly operation of oral complementary drug service prosedure. The research used the cross sectional method of survey which was descriptive and analytic in its nature. The research showed that 74.81% of the patients medication instruction writing in prescription did not fit the requirements in administration writing and medication information completely 7.94% of the patients bought the prescription (76%-1005) form the drug store in RSCM, 42.75% of patients kept the 76%-100% of their drug in the pharmacy depot, 42.75% prepared the 76%-100% of patient prepared the 76%-100% of their drug in unites of doses by the pharmacy depot. 64.12% of the patients were given their drug by nurses directly, and finished to swallow the drug according to its use direction, and there was none of the patients who got CIE service from a pharmacist. The operation of the oral complementary drug service in the nursing wawrd of IRNA B was evaluated as less appropriate to the procedure. It could be concluded that there is significant correlation between medication instruction writing, the orderly operation of the process of the oral complementary drug preservation, the drug preparation, the had-over the oral complementary drug to a patient in the nursing ward of IRNA B with the orderly operation of oral complementary drug service procedure; and there is no correlation between the procurement of the oral complementary drug, the orderly operation of CIE in the nursing ward of IRNA B with the orderly operation of oral complementary drug service procedure.